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CORK Bibliography: Chronic Mental Illness

71 citations. January 2006 to present

Prepared: December 2008

Agabio R; Marras P; Addolorato G; Carpiniello B; Gessa GL. Baclofen suppresses alcohol intake and craving for alcohol in a schizophrenic alcohol-dependent patient - A case report. (letter). Journal of Clinical Psychopharmacology 27(3): 319-320, 2007. (17 refs.)

Baker A; Richmond R; Haile M; Lewin TJ; Carr VJ; Taylor RL et al. Characteristics of smokers with a psychotic disorder and implications for smoking interventions. Psychiatry Research 150(2): 141-152, 2007. (50 refs.)

Despite high rates of smoking among people with psychotic disorders, and the associated health and financial burden, few studies have investigated the characteristics of this group of smokers. This paper reports data from 298 smokers with an ICD-10 psychotic disorder residing in the community (56.7% with schizophrenia or schizoaffective disorder), including an examination of their demographic and clinical characteristics, smoking behaviours, severity of nicotine dependence, stage of change, and reasons for smoking and for quitting. Standardized self-report instruments were used, in conjunction with structured interviews, as part of the first phase of a randomized controlled trial. On average, participants smoked 30 cigarettes per day, commenced smoking daily at about 18 years of age (5 years before illness onset), and had made 2-3 quit attempts in their lifetime. Higher levels of nicotine dependence and concurrent hazardous use of alcohol or cannabis were associated with a younger age at smoking initiation. The present sample was also more likely to report stress reduction, stimulation and addiction as reasons for smoking, compared to a general sample of smokers. Males, precontemplators and participants with concurrent hazardous substance use cited fewer reasons for quitting smoking. These and other subgroup differences in smoking characteristics are used to illustrate potential implications for the nature and timing of smoking interventions among people with a psychotic disorder.

Bangalore SS; Prasad KMR; Montrose DM; Goradia DD; Diwadkar VA; Keshavan MS. Cannabis use and brain structural alterations in first episode schizophrenia: A region of interest, voxel based morphometric study. Schizophrenia Research 99(1-3): 1-6, 2008. (29 refs.)

Structural alterations of the brain in schizophrenia have been associated with genetic and environmental factors. Among the environmental factors, cannabis use has been associated with increased risk for patients with schizophrenia, but the effect of cannabis on their brain structure is unclear. We examined gray matter alterations in first episode schizophrenia patients (FES) with cannabis use (FES + C; n = 15) compared to FES without cannabis use (FES - C; n = 24) and 42 healthy controls who did not use cannabis. We conducted a voxel based morphometric analysis of a priori determined regions of interest consisting of the CB I receptor rich brain regions. We observed a decrease in gray matter density in the right posterior cingulate cortex (PCC) in FES + C when compared with FES-C. The results suggest that cannabis use may be associated with altered brain structure, in particular regions rich in CB I receptors. These findings need to be confirmed by larger, prospective studies.

Batki SL; Dimmock JA; Wade M; Gately PW; Cornell M; Maisto SA; Carey KB et al. Monitored naltrexone without counseling for alcohol Abuse/Dependence in schizophrenia-spectrum disorders. American Journal on Addictions 16(4): 253-259, 2007. (29 refs.)

This clinical trial assessed the effects of monitored naltrexone treatment in 19 subjects with schizophrenia spectrum and alchol use use disorders in an eight-week pro-spectrum and open pilot study. Naltrexone was directly administered to subjets in oral doses of 100mg on Mondays and Wednesdays, and 150mg on Fridays. Subjects received reimbursement for attending the tree weekly study visits. Subjects continued to receive their usual psychiatric care with no added alcohol counseling provided. Alcohol use was assessed by self-report and biomarkers. Psychosis severity was measured by the Positive and Negative Syndrome Scale (PANSS). Subjects reported significant reductions in their number of drinks per week, drinks per drinking day, days of drinking to intoxication, and alcohol craving. Subjects also showed significant reductions in Addication Severity Index (ASI) alcohol composite scores and in PANSS positive, negative and general psycho-pathology scores.

Benda BB. Survival analyses of social support and trauma among homeless male and female veterans who abuse substances. American Journal of Orthopsychiatry 76(1): 70-79, 2006. (82 refs.)

This appears to be the 1st study of gender differences in how well various forms of trauma and social support predict homeless substance abusers' tenure in the community without rehospitalization. Sexual and physical abuses at different stages of the life span, combat exposure, and recent traumatic events were analyzed with social support factors via Cox's proportional hazard model of survival in a 2-year follow-up. The survival models showed similarities and dissimilarities in predictors of tenure in the community for women compared to men among homeless veterans. Traumata and related factors (e.g., depression and suicidal thoughts) were more potent (negative) predictors of tenure, and family and friends were more important social supports, for women than for men. Men's tenure was more positively associated with job satisfaction and more negatively related to substance abuse, combat exposure, cognitive impairments, aggression, and physical health problems. The intervention implications of these findings are discussed.

Borras L; Huguelet P. Schizophrenia and pathological gambling. American Journal on Addictions 16(4): 269-271, 2007. (15 refs.)

High rates of pathological gambling are found in psychiatric populations, including those it,with mood or substance use disorders. The extent to which individual with schizophrenia exhibit the symptoms of pathological gambling has not been adequately investigated. This paper examines the case of a 40-year-old schizophrenic female with a four-year history of gambling. The characteristics of possible interactions between pathological gambling and schizophrenic symptom profiles are outlined in order to propose better treatments for this group of patients.

Brown ES. Introduction. The challenges of dual diagnosis: Managing substance abuse in severe mental illness. (editorial). Journal of Clinical Psychiatry 67(Supplement 7): 3-4, 2006. (3 refs.)

Brunette MF; Drake RE; Xie HY; McHugo GJ; Green AI. Clozapine use and relapses of substance use disorder among patients with co-occurring schizophrenia and substance use disorders. Schizophrenia Bulletin 32(4): 637-643, 2006. (48 refs.)

Background: Previous correlational research with schizophrenic patients has suggested that the second-generation antipsychotic medication clozapine helps to induce remissions of substance use disorder in patients with co-occurring psychosis and substance abuse. This research, however, could be biased by selection factors. Studying patients who are currently in substance abuse remission could control for level of motivation to stop using substances and other methodological confounds. Methods: To test whether clozapine was associated with prevention of substance abuse relapses, we examined patients with schizophrenia or schizoaffective disorder who were in their first 6-month remission of substance use disorder during a prospective 10-year follow-up study. All patients received yearly multimodal assessments of substance use. Antipsychotic medications were prescribed by community doctors as part of usual clinical care. Results: Patients using clozapine at the first 6-month period of substance abuse remission (n = 25) were much less likely to relapse over the next year compared with those on other antipsychotic medications (n = 70): 8.0% vs 40.0%, chi(2) = 8.73 (df = 1), P = .003. Although medication assignment was not randomized, several potential confounders were similar between the groups. Conclusion: Clozapine should be considered for the treatment of patients with schizophrenia and co-occurring substance use disorder to prevent relapses to substance abuse.

Public Domain

Brunette MF; Mueser KT. Psychosocial interventions for the long-term management of patients with severe mental illness and co-occurring substance use disorder. Journal of Clinical Psychiatry 67(Supplement 7): 10-17, 2006. (59 refs.)

People with severe mental illness and co-occurring substance use disorders, also referred to as dual disorders, experience worse outcomes over the long term than people without co-occurring substance abuse. Integrated treatment of both disorders has been shown to be more effective than separate treatments offered in parallel or in sequence. The principles and strategies of integrated dual disorder treatment (IDDT) include integration of treatments for the mental illness and the addiction, use of strategies to engage people in treatment, use of pharmacologic and psychosocial interventions that are matched to the patient's stage of change, and use of a long-term perspective. The stages of change, the stages of treatment, and the psychosocial strategies used at each stage of treatment are outlined.

Buckley PF. Prevalence and consequences of the dual diagnosis of substance abuse and severe mental illness. Journal of Clinical Psychiatry 67(Supplement 7): 5-9, 2006. (37 refs.)

The co-occurrence of a severe mental illness and a substance use or abuse disorder is common in the United States as well as internationally and could be considered as more the expectation than the exception when assessing patients with serious mental illness. Substance use disorders can occur at any phase of the mental illness, perhaps even inducing psychosis. Causes of this comorbidity may include self-medication, genetic vulnerability, environment or lifestyle, underlying shared origins, and/or a common neural substrate. The consequences of dual diagnosis include poor medication compliance, physical comorbidities and poor health, poor self-care, increased suicide risk or aggression, increased sexual behavior, and possible incarceration. All of these factors contribute to a greater health burden, which reduces the health care system's capacity to adequately treat patients. Therefore, screening, assessment, and integrated treatment plans for dual diagnosis that can address both the addiction disorder and the mental illness are recommended in order to provide accurate treatment, aftercare, and other health care to accommodate patients' social and vocational needs.

Caton CLM; Hasin DS; Shrout PE; Drake RE; Dominguez B; Samet S et al. Predictors of psychosis remission in psychotic disorders that co-occur with substance use. Schizophrenia Bulletin 32(4): 618-625, 2006. (45 refs.)

Objective: To examine rates and predictors of psychosis remission at 1-year follow-up for emergency admissions diagnosed with primary psychotic disorders and substance-induced psychoses. Method: A total of 319 patients with comorbid psychosis and substance use, representing 83% of the original referred sample, were rediagnosed at 1 year postintake employing a research diagnostic assessment. Remission of psychosis was defined as the absence of positive and negative symptoms for at least 6 months. Likelihood ratio chi-square tests and multivariate logistic regression were the main means of analysis. Results: Of those with a baseline diagnosis of primary psychotic disorder, 50% were in remission at 1 year postintake, while of those with a baseline diagnosis of substance-induced psychosis, 77% were in remission at this time point. Lower Positive and Negative Syndrome Scale (PANSS) symptom levels at baseline, better premorbid functioning, greater insight into psychosis, and a shorter duration of untreated psychosis predicted remission at 1 year in both diagnostic groups. No interaction effects of baseline predictors and diagnosis type were observed. A stepwise multivariate logistic regression holding baseline diagnosis constant revealed the duration of untreated psychosis (odds ratio [OR] = 0.97; 95% confidence interval [CI] = 0.95, 0.997), total PANSS score (OR = 0.98; 95% CI = 0.97, 0.987), Premorbid Adjustment Scale score (OR = 0.13; 95% CI = 0.02, 0.88), and Scale to Assess Unawareness of Mental Disorders unawareness score (OR = 0.84; 95% CI = 0.71, 0.993) as key predictors of psychosis remission. Conclusions: The association of better premorbid adjustment, a shorter duration of untreated psychosis, better insight into psychotic symptoms, and lower severity of psychotic symptoms with improved clinical outcome, reported previously in studies of schizophrenia, generalizes to psychosis remission in psychotic disorders that are substance induced.

Public Domain

Croissant B; Klein O; Gehrlein L; Kniest A; Hermann D; Diehl A et al. Quetiapine in relapse prevention in alcoholics suffering from craving and affective symptoms: a case series. European Psychiatry 21(8): 570-573, 2006. (25 refs.)

Purpose: Quetiapine is a novel antipsychotic, which is efficacious in the treatment of positive and negative symptoms in schizophrenia. Research has shown that atypical antipsychotic also reduce the craving and consumption for stimulants and alcohol. Due to Quetiapine's particulars and the promising receptor profile concerning addiction medicine, we set out to examine the tolerability and efficacy concerning relapse prevention of withdrawn alcoholics suffering from craving and affective symptoms. Subjects and methods: Our case observations attempted to evaluate nine alcoholics after withdrawal suffering from persisting craving, sleep disorder, excitement, depressive symptoms or anxiety symptoms. The patients were treated with quetiapine as relapse prevention and we followed them up in our outpatient clinic. Results: Eight out of nine patients were abstinent under quetiapine over a period of 2-7 months. One of these patients relapsed after he stopped taking the preparation at his own initiative after 10 weeks. The ninth patient stopped taking the preparation immediately because of swollen nasal mucosae. All target symptoms disappeared in the patients after an average of (mean +/- S.D.) 24.5 +/- 18.1 days. The overall tolerability was considered to be very good; however, initial sleepiness appeared in four patients. Conclusion: Although uncontrolled case observations can only be interpreted with caution quetiapine seems to deserve further investigation and may hold the potential for preventing alcohol relapse in alcoholics suffering from additional above-mentioned symptoms.

Deas D. Adolescent substance abuse and psychiatric comorbidities. Journal of Clinical Psychiatry 67(Supplement 7): 18-23, 2006. (32 refs.)

Substance use disorders have a serious impact on adolescents because these disorders have high prevalence rates and frequent associations with psychiatric disorders. Surveys of adolescent behaviors and substance use show that alcohol is the most common substance abused by adolescents. Despite the high rates of current alcohol use and binge drinking among adolescents, current diagnostic criteria are problematic. Adolescents may have a developing problem with substance dependence but not meet criteria for either substance abuse or dependence. At-risk adolescents, called "diagnostic orphans," may meet only 1 or 2 criteria for alcohol dependence and no abuse criteria and therefore do not receive an alcohol use disorder diagnosis from the Diagnostic and Statistical Manual of Mental Disorders, Fourth Edition, Text Revision. Adolescents with substance use disorders tend to have higher rates of comorbid psychiatric disorders and are more likely to report a history of trauma and physical and/or sexual abuse than adolescents without a substance use disorder. In addition, psychiatric disorders in adolescents often predate the substance use disorder. Once the substance use disorder develops, the psychiatric disorder may be further exacerbated.

Drake RE; McHugo GJ; Xie HY; Fox M; Packard J; Helmstetter B. Ten-year recovery outcomes for clients with co-occurring schizophrenia and substance use disorders. Schizophrenia Bulletin 32(3): 464-473, 2006. (57 refs.)

The long-term courses of people with schizophrenia and of those with substance use disorder have been studied separately and extensively. The long-term course of clients with co-occurring schizophrenic and substance use disorders has, however, not been examined. This article reports 10-year outcomes for 130 clients with co-occurring schizophrenic and substance use disorders in the New Hampshire Dual Diagnosis Study. In addition, we report on 6 "recovery outcomes," identified by dual diagnosis clients, as examples of positive coping behaviors. Longitudinal data were modeled using generalized estimating equation (GEE) methods. Participants improved steadily over 10 years in the outcome domains of symptoms, substance abuse, institutionalization, functional status, and quality of life. Further, at the 10-year follow-up, substantial proportions were above cutoffs selected by dual diagnosis clients as indicators of recovery: 62.7% were controlling symptoms of schizophrenia; 62.5% were actively attaining remissions from substance abuse; 56.8% were in independent living situations; 41.4% were competitively employed; 48.9% had regular social contacts with non-substance abusers; and 58.3% expressed overall life satisfaction. These 6 outcomes were only weakly interrelated over time, suggesting that recovery, as defined by clients, is a multidimensional concept. Overall, the 10-year findings on recovery outcomes provide a hopeful long-term perspective for dual diagnosis clients.

D'Souza DC. Cannabinoids and psychosis. (review). Integrating the Neurobiology of Scizophrenia 78: 289-+, 2007. (162 refs.)

Recent epidemiological studies and advances in understanding of brain cannabinoid function have renewed interest in the long-recognized association between cannabinolds and psychosis. This chapter presents evidence supporting and refuting the association between cannabinoids and psychosis. Cannabinoids can induce acute transient psychotic symptoms or an acute psychosis in some individuals. What makes some individuals vulnerable to cannabinoid-related psychosis is unclear. Also clear is that cannabinoids can also exacerbate psychosis in individuals with an established psychotic disorder, and these exacerbations may last beyond the peniod of intoxication. Less clear is whether cannabis causes a persistent de novo psychosis. The available evidence meets many but not all the criteria for causality, including dose-response, temporality, direction, specificity, and biological plausibility. On the other hand, the large majority of individuals exposed to cannabinoids do not experience psychosis or develop schizophrenia and the rates of schizophrenia have not increased commensurate with the increase in rates of cannabis use. Similar to smoking and lung cancer, it is more likely that cannabis exposure is a component cause that interacts with other factors, for example, genetic risk, to "cause" schizophrenia. Nevertheless, in the absence of known causes of schizophrenia, the role of component causes such as cannabis exposure (exogenous hypothesis) is important and warrants further study. There is also tantalizing evidence from postmortem, neurochemical, and genetic studies suggesting CB I receptor dysfunction (endogenous hypothesis) in schizophrenia that warrants further investigation. Further work is necessary to identify those factors that place individuals at higher risk for cannabinold-related psychosis, to identify the biological mechanisms underlying the risks and to further study whether CBI receptor dysfunction contributes to the pathophysiology of psychotic disorders.

Dubertret C; Bidard I; Ades J; Gorwood P. Lifetime positive symptoms in patients with schizophrenia and cannabis abuse are partially explained by co-morbid addiction. Schizophrenia Research 86(1-3): 284-290, 2006. (24 refs.)

Recent prospective findings have shown that cannabis use by young people could be a risk factor for psychotic symptoms in adulthood, but the long-term impact of cannabis abuse on the clinical features of declared schizophrenia remains to be explored. We assessed the independent influence of cannabis abuse on the clinical symptoms of schizophrenia, after controlling for frequently co-occurring addictive disorders. Patients with schizophrenia, and with (N= 66), or without (N= 139) cannabis abuse, were compared for lifetime positive and negative symptoms, taking into account presence of any other addictive disorders. The incidence of the abuse of drugs other than cannabis was nearly five times greater amongst patients with both schizophrenia and cannabis abuse. When the analyses were limited to subjects with no other abuse, less avolution and fewer apathy symptoms were still detected in patients with schizophrenia and cannabis abuse than in those with no abuse (p=0.0001). In contrast, between-group differences for positive symptoms were abolished when multiple substance abuses were taken into account. The strong association between cannabis abuse and fewer negative symptoms in schizophrenia was thus replicated in this sample, but once co-morbid addictive disorders had been controlled no influence of cannabis abuse on hallucinations was detected. Distinguishing the effects of co-occurring addictive disorder(s) in patients with schizophrenia and cannabis dependence may thus be important when attempting to analyse the impact of cannabis abuse.

Ejaz S; Lim CWCampo-Arias A Diaz-Martinez LA Rueda-Jaimes GE Rueda-Sanchez M Farelo-Palacin D Diaz FJ et al. Smoking is associated with schizophrenia, but not with mood disorders, within a population with low smoking rates: A matched case-control study in Bucaramanga, Colombia. Schizophrenia Research 83(2-3): 269-276, 2006. (28 refs.)

When comparing current smoking in schizophrenia patients versus the general population, the average odds ratio (OR) was 5.3 in a meta-analysis of 42 studies from 20 nations. Limited tobacco access can eliminate this strong association in some nations. Out of the 42 ORs, 37 were significantly higher than 1. Of the 5 non-significant ORs, three came from, Colombian studies comparing current smoking prevalences in schizophrenia versus those in the general population (18%). However, the 3 ORs were not adjusted for confounders. We hypothesized that the association between schizophrenia and smoking is so strong that it can be detected in populations with limited access to smoking after carefully controlling for confounders. Of the three Colombian studies, one included 73 schizophrenia patients (DSM-IV schizophrenia or schizoaffective disorder) and 111 patients with mood disorders (DSM-IV bipolar or major depressive disorders). The current study matched each of these patients with 2 controls from the general population and performed more sophisticated statistical analyses. Prevalences of current smoking were 26% for schizophrenia patients and 10% for their matched controls (adjusted Mantel-Haenszel OR = 3.1, 95% CI, 1.4-6.8), and 7% for patients with mood disorders and 12% for their matched controls (adjusted Mantel-Haenszel OR = 0.62; CI, 0.28-1.4). The previously observed lack of association between schizophrenia and current smoking was due to lack of control of important confounding variables because of the absence of a control group. This re-analysis, which used a careful matching that controlled for confounders, suggests that the association between schizophrenia and smoking behaviors can stand in populations with low monetary income and low smoking rates. This study also suggests that the association between severe mood disorders (bipolar and major depression) and smoking is not as strong as that observed between schizophrenia and smoking, and may not be observable in countries where people have limited economic resources.

Elbogen EB; Beckham JC; Butterfield MI; Swartz M; Swanson J. Assessing risk of violent behavior among veterans with severe mental illness. Journal of Traumatic Stress 21(1): 113-117, 2008. (24 refs.)

Although empirical research has examined factors associated with increased violence risk among individuals with severe mental illness (SMI) and among veterans without severe mental illness, less attention has been devoted to identifying violence risk factors among veterans with severe mental illness. Using multivariable analysis of a large pooled sample of individuals with SMI this study examines violence risk factors of N = 278 veterans with severe mental illness, In multivariate modeling, violence by veterans with SMI was associated with head injury, posttraumatic stress disorder (PTSD), substance abuse, and homelessness. Results support the view clinicians assessing violence risk among veterans with severe mental illness should consider a combination of characteristics empirically related to violence by non-veterans with

Eriksson A; Tengstrom A; Hodgins S. Typologies of alcohol use disorders among men with schizophrenic disorders. Addictive Behaviors 32(6): 1146-1163, 2007. (56 refs.)

Alcohol use disorders are common among persons with schizophrenia and are associated with a vast array of negative consequences: criminality, poor compliance with treatment, and reoccurrence of acute episodes of psychosis. In samples of non-mentally disordered individuals, typologies of alcohol use disorders have been shown to be useful in furthering understanding of etiology and of effective treatments. Such typologies, however, have not previously been examined in individuals with schizophrenia. The main objective of the study was to validate four uni-dimensional typologies and the multi-dimensional Type I/II - Type A/B typology in a sample of men with schizophrenic disorders and alcohol use disorders. All uni-dimensional typologies showed at least some degree of concurrent validity. The Type I/II - Type A/B typology was successfully replicated with fair concurrent validity across the domains of pre-morbid risk factors and drug use, but not for the domains of criminality, illness, or personality. The predictive validity was poor for all typologies. The results provide evidence for the heterogeneity of alcohol use disorders among men with schizophrenia.

Fisher WH; Wolff N; Grudzinskas AJ; Roy-Bujnowski K; Banks SM; Clayfield J. Drug-related arrests in a cohort of public mental health service recipients. Psychiatric Services 58(11): 1448-1453, 2007. (20 refs.)

Objectives: The excessive prevalence of comorbid substance abuse among persons with severe mental illness has been well established and identified as the source of numerous negative outcomes. An overlooked aspect of illicit drug use in this population is its illegality and the potentially dire criminal sanctions. This study examined the prevalence of drug arrests in a cohort of persons receiving services from a state mental health agency who were followed for roughly ten years. Methods: Data on arrest spanning from 1991 to 2000 were obtained for all individuals receiving inpatient, case management, or residential services from July 1991 to June 1992 (N=13,816). Reports of prevalence were based on the number with at least one drug-related arrest in the observation period. Results: Five percent of individuals in the cohort experienced at least one drug-related arrest (N=720). These included simple possession as well as manufacturing and distribution. The prevalence was much higher (15%) among persons aged 18 to 25 years than in other age groups. Roughly 95% of persons with a drug arrest also had an arrest for another type of offense. This pattern is similar to that observed among persons with a drug-related arrest in the general population. Conclusions: Convictions on drug charges can void access to Section Eight housing and other benefits and are associated with other patterns of offending that also carry significant criminal sanctions. State mental health agencies may wish to target interventions toward youthful clientele by focusing specifically on the risks associated with involvement with illicit drugs.

Friedman L; Turner JA; Stern H; Mathalon DH; Trondsen LC; Potkin SG. Chronic smoking and the BOLD response to a visual activation task and a breath hold task in patients with schizophrenia and healthy controls. Neuroimage 40(3): 1181-1194, 2008. (81 refs.)

Many psychiatric patient groups smoke heavily, but little is known regarding the effects of this habit on functional brain imaging results. The present report assesses the effect of chronic smoking on the blood oxygen level-dependent (BOLD) response to a simple visual activation (VA) task and a breath hold (BH) task in patients with schizophrenia. Eight healthy controls and twelve patients with schizophrenia were studied. Half of each group had never smoked and the other half of each group had smoked for more than 10 pack years. Responses to the VA task were assessed in the visual cortex and responses to the BH task were assessed in gray matter generally. There were four fMRI-dependent measures: (1) median percent signal change; (2) activation volume (in voxels); (3) time-to-peak of the impulse response function (IRF); and (4) time-to-trough of the IRF. All measures were tested as dependent variables in an ANCOVA with diagnosis and smoking status as crossed factors and age as a covariate. Heavy smokers had 22% larger percent signal change for the VA task and 50% larger percent signal change for the BH task. Patients had a 40% larger percent signal change for the breath hold task. Other statistically significant effects of smoking history on activation volume and the timing of the brain responses were noted. If replicated, the results may have important implications for fMRI studies comparing groups with markedly different smoking habits, such as studies comparing patients with schizophrenia, 60-90% of whom smoke, and healthy controls, who smoke with a much lower frequency.

Goldberg JO; Van Exan J. Longitudinal rates of smoking in a schizophrenia sample. Tobacco Control 17(4): 271-275, 2008. (29 refs.)

Objectives: Despite the well documented link between high rates of smoking and schizophrenia, there have been no longitudinal studies that have looked at rates of smoking and associated factors over time. This prospective study examined the longitudinal rates of smoking in a schizophrenia clinic sample over a decade. Methods: Longitudinal survey research was conducted in a well established community-based psychiatric rehabilitation program in Hamilton, Ontario, Canada, providing long-term intensive case management and rehabilitation skills training. Stable community outpatients diagnosed with schizophrenia were surveyed initially in 1995 (n = 102) and then resurveyed 11 years later in 2006 (n = 76). The main outcome measure was self-report of smoking status. Results: Smoking rates dropped significantly over time, with evidence that the number of "quitters'' tripled over the past decade and the number of "everyday'' smokers decreased by almost a third from 63.2% down to 43.3% (p < 0.001). Conclusions: The findings from the present study suggest that it is possible to obtain reduced smoking prevalence over time in a selected schizophrenia outpatient sample, though further research is required to better understand the factors related to quitting smoking in individuals with schizophrenia.

Gonzalez VM; Bradizza CM; Vincent PC; Stasiewicz PR; Paas ND. Do individuals with a severe mental illness experience greater alcohol and drug-related problems? A test of the supersensitivity hypothesis. Addictive Behaviors 32(3): 477-490, 2007. (38 refs.)

The supersensitivity hypothesis posits that individuals with a severe mental illness (i.e., schizophrenia and bipolar disorder; SMI) are more likely to be diagnosed with a substance abuse as opposed to a substance dependence diagnosis, and experience greater negative consequences associated with substance use at lower levels of consumption, as compared with non-SMI substance abusers. This is the first known study to test this hypothesis with a control group of non-SMI substance abusing individuals. Forty-two individuals with only a substance use disorder (SUD-only) and 53 dually diagnosed individuals (DD) were compared on measures of substance use, alcohol and drug dependence, negative consequences, substance use outcome expectancies, and motivation for change. A third group of SMI-only individuals (i.e., no SUD; n=35) were also recruited and all three groups were compared on psychological symptoms. Substance use, negative consequences, substance use outcome expectancies, motivation for change, and severity of alcohol and drug dependence were not found to differ significantly between the DD and SUD-only groups. However, the DD group had significantly greater levels of psychological symptoms, as compared with the SMI-only and SUD-only groups. Overall, this study does not provide support for the supersensitivity hypothesis.

Green AI. Pharmacotherapy for schizophrenia and co-occurring substance use disorders. Neurotoxicity Research 11(1): 33-39, 2007. (79 refs.)

Substance use disorder (SUD) occurs commonly in patients with schizophrenia and is associated with a poor outcome. Despite this common comorbid occurrence (and its negative impact on the course of schizophrenia), there have been very few studies assessing pharmacological strategies for optimal treatment of these patients. A number of theories have been advanced to help explain the high rate of substance use disorder in patients with schizophrenia. Our group has suggested that the brain reward circuit dysfunction model, which may incorporate aspects of all of these models, may help direct research aimed at developing new pharmacological treatments for patients with schizophrenia and co-occurring SUD. Although typical antipsychotic medications appear to be of limited value in these patients, emerging, but preliminary, data suggest that the atypical antipsychotics, particularly clozapine, may be particularly helpful. The role of adjunctive medications, such as those medications that have recently been shown to be useful for the treatment of alcoholism, may have a role in the treatment of these patients, although only naltrexone has, thusfar, been carefully tested in these comorbid patients. Further studies are indicated to assess the role of novel pharmacologic treatment strategies for these patients. Ultimately, any medication given to these patients will need to be prescribed within psychosocial treatment programs aimed at assisting these patients in limiting and ultimately ceasing substance use.

Green AI. Treatment of schizophrenia and comorbid substance abuse: Pharmacologic approaches. Journal of Clinical Psychiatry 67(Supplement 7): 31-35, 2006. (68 refs.)

Co-occurring substance use disorder is common among patients with schizophrenia, and its presence greatly worsens the course of schizophrenia. A number of theories have been introduced to explain the increased rate of substance use disorder in these patients. These theories include the notion that substance use could trigger psychotic symptoms in vulnerable individuals and the idea that the substances are used to self-medicate symptoms of schizophrenia. Our group and others have advanced a neurobiological hypothesis to explain this comorbidity-that a mesocorticolimbic brain reward circuit underlies the substance use disorder in patients with schizophrenia. Treatment of substance use disorder in these patients is best done with integrated treatment programs that combine psychosocial interventions with pharmacotberapy. Recent data suggest that the atypical antipsychotic clozapine and perhaps other atypical agents may lessen substance use in patients with schizophrenia. My colleagues and I have proposed that clozapine's effect in these patients may be related to its ability to decrease the brain reward circuit dysfunction. Research is continuing on the use of atypical antipsychotics in patients with schizophrenia and comorbid substance abuse. The adjunctive use of naltrexone or other agents also may be helpful. Further research on the optimal pharmacologic approach to patients with dual diagnosis is needed.

Green AI; Drake RE; Brunette MF; Noordsy DL. Schizophrenia and co-occurring substance use disorder. American Journal of Psychiatry 164(3): 402-408, 2007. (41 refs.)

Nearly 50% of patients with schizophrenia develop a substance use disorder in their lifetime, and this co-occurring disorder substantially worsens the course of schizophrenia by destabilizing the illness, impeding treatment adherence, and adding the problems of psychosocial instability, legal entanglements, and medical illnesses to the challenge of managing psychotic symptoms. While the basis of the high rate of substance abuse in this patient group is uncertain, it appears that these patients are highly vulnerable to the effects of alcohol and other drugs and that they suffer from an accumulation of known risk factors for the development of substance abuse disorder. Following the presentation of a case vignette, the article provides an overview of schizophrenia and co-occurring substance use disorders, theories of the possible basis for co-occurrence, detection of substance abuse problems in patients with schizophrenia, integrated treatment and drug therapies.

Green AI; Noordsy DL; Brunette MF; O'Keefe C. Substance abuse and schizophrenia: Pharmacotherapeutic intervention. (review). Journal of Substance Abuse Treatment 34(1): 61-71, 2008. (123 refs.)

Substance use disorder is common in patients with schizophrenia and dramatically worsens their outcome. The typical antipsychotic medications, introduced more than 50 years ago, are effective for the treatment of psychosis but may have only limited efficacy in patients with these co-occurring disorders because patients continue to use substances while taking them. In preliminary studies, however, several of the atypical antipsychotic medications have shown promise for reducing alcohol and drug use in patients with schizophrenia. A neurobiological formulation is discussed, suggesting that the use of substances in patients with schizophrenia may be based on a dysfunction within the dopamine-mediated brain reward circuitry and that clozapine, in particular, may potentially ameliorate this dysfunction and lessen the desire for substance use. Medications for the treatment of alcohol use disorders, such as disulfiram, naltrexone, and acamprosate, as well as other adjunctive medications, may also be useful. Further studies are required to establish a solid evidence base of best practices for the use of medications in these patients.

Gregg L; Barrowclough C; Haddock G. Reasons for increased substance use in psychosis. (review). Clinical Psychology Review 27(4): 494-510, 2007. (142 refs.)

Around half of all patients with schizophrenia are thought to abuse drugs or alcohol and there is good evidence to suggest that they have poorer outcomes than their non substance using counterparts. However, despite more than twenty years of research there is still no consensus on the aetiology of increased rates of substance use in people with psychosis. There is a clear need to understand the reasons for such high rates of substance use if treatments designed to help patients abstain from substance use are to be successful. This paper provides an update of the literature examining the reasons for substance use by people with psychosis, and includes a comprehensive review of the self report literature. The main theories as to why people with psychosis use substances are presented. There is evidence to suggest that cannabis may have a causal role in the development of psychopathology but not for other substances. The self report literature provides support for an 'alleviation of dysphoria' model of substance use but there is little empirical support for the self medication hypothesis, or for common factor models and bidirectional models of comorbidity. It is likely that there are multiple risk factors involved in substance use in psychosis and more work to develop and test multiple risk factor models is required.

Gurpegui M; Aguilar MC; Martinez-Ortega JM; Jurado D; Diaz FJ; Quintana HM et al. Fewer but heavier caffeine consumers in schizophrenia: A case-control study. Schizophrenia Research 86(1-3): 276-283, 2006. (34 refs.)

According to the literature, there is an association between schizophrenia and caffeine consumption, but it is not clear whether schizophrenia is associated with either higher prevalence of daily caffeine intake or the amount consumed. In this study we compared our previously published schizophrenia patients (n = 250) with a control sample (n = 290) after controlling for demogaphic variables and tobacco and alcohol consumption. Current caffeine intake was less frequent in schizophrenia patients (59%, 147/250) than in controls (70%, 204/290). In the multivariate analyses, caffeine intake was less frequent at an older age and in schizophrenia patients, and more frequent in smokers and alcohol users. Among caffeine consumers, heavy caffeine intake (>= 200 mg/day) was significantly associated with schizophrenia (64%, 94/147 in schizophrenia versus 36%, 73/204 in controls), as well as older age and smoking. Daily amount of caffeine intake and smoked cigarettes correlated significantly in the schizophrenia group but not in the control group; the correlation of caffeine intake with nicotine dependence was low and non-significant in both groups. The association between current smoking and heavy caffeine intake may be partly explained by a pharmacokinetic effect: tobacco smoke compounds induce caffeine metabolism by the cytochrome P450 1A2. Although schizophrenia by itself may be associated with heavy caffeine intake in caffeine users, part of this association was explained by the association between schizophrenia and smoking. The relationship between caffeine and alcohol intake appeared to be more complex; alcohol and caffeine use were significantly associated, but within caffeine users alcohol was associated with less frequent heavy caffeine consumption among smokers. In future studies, the measurement of plasma caffeine levels will help both to better define heavy caffeine intake and to control for smoking pharmacokinetic effects.

Haddock G; Barrowclough C. Psychosis and substance use problems: Using controlled drinking in interventions. Addiction Research & Theory 14(1): 67-72, 2006. (22 refs.)

Substance use is a significant problem for people with severe mental health problems such as schizophrenia. It has a high prevalence and is linked to poor clinical and social outcomes. Reasons for substance using in this population are wide-ranging and overlap with those found in non-psychotic populations. Services have traditionally not been well configured to deal with people with dual problems of psychosis and substance use leading to this group's needs not being well addressed. Current guidance from the Department of Health is attempting to address this. Treatment strategies have not, as yet, been well researched. However, some conclusions can be made about the types of treatment that are acceptable and show promise. There is an emphasis on providing treatment programmes that integrate treatment for both psychosis and substance use, incorporate motivational approaches, allow flexibility in treatment goals (such as controlled drinking rather than abstinence) and incorporate some form of individual therapy (usually cognitive-behavioural) intervention. Further research is needed to expand the evidence base around interventions for psychosis and substance use.

Hides L; Dawe S; Young RM; Kavanagh DJ. The reliability and validity of the Severity of Dependence Scale for detecting cannabis dependence in psychosis. Addiction 102(1): 35-40, 2007. (31 refs.)

To determine the reliability and validity of the Severity of Dependence Scale (SDS) for detecting cannabis dependence in a large sample of in-patients with a schizophrenia spectrum disorder. Cross-sectional study. Participants were 153 in-patients with a schizophrenia spectrum disorder in Brisbane, Australia. Participants were administered the SDS for cannabis dependence in the past 12 months. The presence of Diagnostic and Statistical Manual Version-IV (DSM-IV) cannabis dependence in the previous 12 months was assessed using the Comprehensive International Diagnostic Interview (CIDI). The SDS had high levels of internal consistency and strong construct and concurrent validity. Individuals with a score of >= 2 on the SDS were nearly 30 times more likely to have DSM-IV cannabis dependence. The SDS was the strongest predictor of DSM-IV cannabis dependence after controlling for other predictor variables. The SDS is a brief, valid and reliable screen for cannabis dependence among people with psychosis.

Jubelt LE; Barr RS; Goff DC; Logvinenko T; Weiss AP; Evins A. Effects of transdermal nicotine on episodic memory in non-smokers with and without schizophrenia. Psychopharmacology 199(1): 89-98, 2008. (79 refs.)

Rationale: Nicotinic agonists may improve attention and memory in humans and may ameliorate some cognitive deficits associated with neuropsychiatric disorders such as schizophrenia. Materials and methods We investigated the effects of a single dose of nicotine on episodic memory performance in 10 adults with schizophrenia and 12 healthy controls. Participants were nonsmokers in order to avoid confounding effects of nicotine withdrawal and reinstatement on memory. At each of two study visits, participants performed a test of episodic memory before and 4 h after application of a 14-mg transdermal nicotine ( or identical placebo) patch in counterbalanced order. Results: Compared with placebo, nicotine treatment was associated with more rapid and accurate recognition of novel items. There was a trend for a treatment by diagnosis interaction, such that the effect of nicotine to reduce false alarms was stronger in the schizophrenia than the control group. There was no effect of nicotine on accuracy or reaction time for identification of previously viewed items. Conclusions: These data suggest that nicotine improves novelty detection in non-smokers, an effect that may be more pronounced in non-smokers with schizophrenia. Because memory deficits are associated with functional impairment in schizophrenia and because impaired novelty detection has been linked to the positive symptoms of schizophrenia, study of the effects of chronic nicotinic agonist treatment on novelty detection may be warranted.

Junginger J; Claypoole K; Laygo R; Crisanti A. Effects of serious mental illness and substance abuse on criminal offenses. Psychiatric Services 57(6): 879-882, 2006. (11 refs.)

Objective: Some believe serious mental illness has been "criminalized." Effects of serious mental illness and substance abuse on criminal offenses were studied for 113 postbooking jail diversion participants and their nondiverted counterparts. Methods: Raters read participants' and police report descriptions of criminal offenses and participants' explanations for them. Using 5-point scales, raters independently estimated whether an offense resulted directly or indirectly from serious mental illness or substance abuse. Results: Serious mental illness and substance abuse had little effect on offenses. However, substance abuse led to a sizable minority of offenses and was more likely than mental illness to cause an offense. Conclusions: Unless factors unique to serious mental illness can be specifically associated with behavior leading to incarceration, the criminalization hypothesis should be reconsidered in favor of more powerful risk factors for crime that are widespread in social settings of persons with serious mental illness.

Kedzior KK; Martin-Iverson MT. Chronic cannabis use is associated with attention-modulated reduction in prepulse inhibition of the startle reflex in healthy humans. Journal of Psychopharmacology 20(4): 471-484, 2006. (86 refs.)

Regardless of a wide research interest the nature of a relationship between cannabis use and schizophrenia is controversial. One of the physiological abnormalities in schizophrenia is attention-modulated deficit in prepulse inhibition (PPI), which is a normal reduction in the startle reflex magnitude when a non-startling stimulus (prepulse) precedes the startling stimulus (pulse). This experiment was designed to determine whether or not otherwise healthy people using cannabis would exhibit attention-modulated deficit in PPI. The startle reflex was recorded in carefully screened healthy humans attending to and ignoring auditory pulse and prepulse stimuli separated by short (20-200 ms) and tong prepulse intervals (1600 ms). In contrast to 12 non-using controls, cannabis use in 16 healthy humans was associated with significant reduction in %PPI white attending to auditory stimuli, but not while ignoring them. The PPI was correlated with the duration of cannabis use but not with the concentration of cannabinoid metabolites in urine and the recency of cannabis use in the preceding 24 hours. Cannabis use was not associated with changes in prepulse facititation of startle reflex magnitude (%PPF) at tong prepulse intervals, prepulse facilitation of startle reflex latency and startle reflex magnitude in the absence of prepulses. These results suggest that chronic, but not acute, use of cannabis is associated with schizophrenia-like disruption in PPI in healthy controls. Such reduction in PPI is attention-dependent and does not reflect a global deficit in sensorimotor gating in cannabis users.

Keltner NL; Grant JS. Smoke, smoke, smoke that cigarette. Perspectives in Psychiatric Care 42(4): 256-261, 2006. (38 refs.)

While the use of tobacco within the general population has decline over recent decades, the rate of smoking among people with schizophrenia has not. Those with schizophrenia smoke at a considerably higher rate, with some research suggesting a threefold or more increase in this habit. Data from some studies indicate that 80% or more people with schizophrenia smoke. It has been suggested that those with schizophrenia not only smoke more, they smoke "harder," with significantly higher plasma nicotine levels achieved than in non-schizophrenic smokers. Smoking behaviors include more puffs per cigarette, shorter puff intervals, and larger puff volumes. The authors review physiological factors that may contribute to this phenomenon -- namely, that nicotine causes an increase in synaptic dopamine. It is thought that people with schizophrenia may smoke to compensate for downregulated dopamine expression and receptor binding, specifically that, nicotine modulates dopaminergic tracts that project to both limbic and prefrontal cortical areas (an area of downregulation). Dopaminergic stimulation causes improved mood, sharpened cognition, and decreased appetite. In addition nicotine is associated with a reduction in disease-related symptoms. the article concludes with a discussion of ways in which psychiatric nurses can facilitate smoking cessation.

Kisely S; Campbell LA. Use of smoking cessation therapies in individuals with psychiatric illness - An update for prescribers. CNS Drugs 22(4): 263-273, 2008. (64 refs.)

Individuals with mental illness are particularly disadvantaged by their use of tobacco, spending as much as 40% of their income on cigarettes. They also have increased mortality from cardiovascular and respiratory disorders. The most effective interventions to help psychiatric patients stop smoking are similar to those that are effective in the general population. These include psychological treatments, nicotine replacement therapy (NRT), bupropion and nortriptyline, at least in the short term. Most studies agree that these gains can be achieved in the absence of significant adverse effects in terms of psychological morbidity. Effects diminish over time, but these findings also apply to the general population. The best long-term results have come from extended prescription and psychological interventions, and apply equally to patients with and without a history of psychiatric disorder, such as major depression. In spite of this, clinicians are not fully exploiting opportunities to help psychiatric patients stop smoking. It is not possible to plan a programme to help individuals stop smoking in mental health settings unless factors such as demographics, diagnosis and concurrent medication are taken into account.

Larsen TK; Melle I; Auestad B; Friis S; Haahr U; Johannessen JO et al. Substance abuse in first-episode non-affective psychosis. Schizophrenia Research 88(1-3): 55-62, 2006. (35 refs.)

Abuse of alcohol and drugs is an important and clinically challenging aspect of first-episode psychosis. Only a few studies have been carried out on large-sized and reliably characterized samples. These are reviewed, and the results are compared with a sample of 300 first-episode psychosis patients recruited for the TIPS (Early Treatment and Identification of Psychosis) study from Norway and Denmark. Prevalence rates from the literature vary from 6% to 44% for drugs and 3% to 35% for alcohol. In our sample, 23% abused drugs and 15% abused alcohol during the last 6 months. When compared to non-abusers, the drug-abusing group is characterized by the following: male gender, younger age, better premorbid social, poor premorbid academic functioning, and more contact with friends in the last year before onset. Alcohol abusers were the oldest group and they had the least contact with friends. A group of patients abusing both drugs and alcohol had poor premorbid academic functioning from early childhood. Overall, drug and alcohol abuse are highly prevalent in contemporary first-episode psychosis samples. In our study, substance abuse comorbidity did not generate differences on diagnosis, duration of untreated psychosis, psychiatric symptoms, or global functioning at onset/baseline. The premorbid profiles of the substance abusers were clearly different from the non-abusers. Drug abusers, in particular, were more socially active both premorbidly and during the year preceding the start of treatment.

McGovern MP; Xie HY; Segal SR; Siembab L; Drake RE. Addiction treatment services and co-occurring disorders: Prevalence estimates, treatment practices, and barriers. Journal of Substance Abuse Treatment 31(3): 267-275, 2006. (33 refs.)

As the model for treating co-occurring disorders in addiction treatment settings becomes articulated, service systems need data on prevalence, current practice, and barriers to the implementation of evidence-based practices. A self-report survey was administered to 45 3 addiction treatment providers (43 agency directors, 110 clinical supervisors, and 300 clinicians) from a single state system of care. Data on prevalence estimates, treatment practices, and barriers to implementing services for co-occurring disorders were obtained. The three groups estimated that several co-occurring disorders were extremely common: mood disorders (40%-42%), anxiety disorders (24%-27%), posttraumatic stress disorder (24%-27%), severe mental illnesses (16%-21%), antisocial personality disorder (18%-20%), and borderline personality disorder (17%-18%). Practice patterns for patients with these co-occurring disorders differed widely, from referral to mental health programs to provision of integrated treatment. Common barriers to providing services to persons with co-occurring disorders were lack of psychiatric personnel and resources. Comprehensive surveys of an addiction treatment service system can rapidly and economically produce estimates of prevalence, current practices, and barriers to evidence-based practices. This objective information is critical for systems intending to enhance services to persons with co-occurring disorders.

McHugo GJ; Drake RE; Brunette MF; Xie HY; Essock SM; Green AI. Enhancing validity in co-occurring disorders treatment research. Schizophrenia Bulletin 32(4): 655-665, 2006. (65 refs.)

Despite the high prevalence of co-occurring mental health and substance-use disorders, there has been a relative lack of treatment research with this population, and the existing research often has limited validity. This article explores some of the barriers to the conduct of research on promising interventions for substance-abuse treatment for people with co-occurring disorders, using the concepts of external and ecological validity to make recommendations for future investigation. The central recommendation is to move rapidly from efficacy studies to more credible and valid effectiveness studies, in order to facilitate the adoption of evidence-based interventions in routine practice settings.

Public Domain

Mericle AA; Alvidrez J; Havassy BE. Mental health provider perspectives on co-occurring substance use among severely mentally ill clients. Journal of Psychoactive Drugs 39(2): 173-181, 2007. (32 refs.)

This qualitative study explores strategies used by mental health providers (N = 17) to address substance use problems among seriously mentally ill (SMI) clients and their perspectives on barriers to treatment and how treatment can be improved. Providers identified numerous strategies, yet these were countered with perceptions of multiple obstacles, leaving them frustrated, helpless, and hopeless about their clients' substance use. Results suggest that, in addition to improving access to quality dual-diagnosis treatment, larger issues of poverty and social isolation must also be addressed. Not doing so limits what providers can do for SMI clients and could reduce the effect of larger system-level improvements.

Mobascher A; Winterer G. The molecular and cellular neurobiology of nicotine abuse in schizophrenia. (review). Pharmacopsychiatry 41(Supplement 1): S51-S59, 2008. (115 refs.)

People with schizophrenia Suffer from a variety of symptoms that can be categorized as positive, negative and cognitive symptoms. Cognitive symptoms are not properly treated with antipsychotic medication and are the major cause of disability associated with the disorder. People with schizophrenia smoke more frequently and heavily than the general population. This observation in view of the well established role of nicotinic, cholinergic neurotransmission in cognition led to the hypothesis that people with schizophrenia may use nicotine as a self-medication to ameliorate cognitive symptoms associated with their disease. Furthermore genetic and post-mortem studies point to additional links between nicotinic cholinergic neurotransmission and schizophrenia. This article provides an insight in the possible relationship between schizophrenia and smoking behavior. We focus on the effects of nicotine on individual neurons as well as on neuronal networks. With respect to single neurons the immediate electrophysiological consequences of nicotinic stimulation and the more "metabotropic" effects related to intracellular signal transduction cascades that may lead to plastic changes in the neuron are discussed. With respect to the network level, three systems are discussed: cognition, reward and stress response. The effects of nicotine on cognition may be most pertinent to the problem of schizophrenia, but schizophrenics may also smoke to regulate mood and reduce stress. A better understanding of the molecular and cellular effects of nicotine and how they are related to the pathophysiology and symptomatology of schizophrenia may help to identify new targets for the pharmacotherapy of schizophrenia and of nicotine addiction in schizophrenia.

Mueser KT; Crocker AG; Frisman LB; Drake RE; Covell NH; Essock SM. Conduct disorder and antisocial personality disorder in persons with severe psychiatric and substance use disorders. Schizophrenia Bulletin 32(4): 626-636, 2006. (77 refs.)

Conduct disorder (CD) and antisocial personality disorder (ASPD) are established risk factors for substance use disorders in both the general population and among persons with schizophrenia and other severe mental illnesses. Among clients with substance use disorders in the general population, CD and ASPD are associated with more severe problems and criminal justice involvement, but little research has examined their correlates in clients with dual disorders. To address this question, we compared the demographic, substance abuse, clinical, homelessness, sexual risk, and criminal justice characteristics of 178 dual disorder clients living in 2 urban areas between 4 groups: No CD/ASPD, CD Only, Adult ASPD Only, and Full ASPD. Clients in the Adult ASPD only group tended to have the most severe drug abuse severity, the most extensive homelessness, and the most lifetime sexual partners, followed by the Full ASPD group, compared with the other 2 groups. However, clients with Full ASPD had the most criminal justice involvement, especially with respect to violent charges and convictions. The results suggest that a late-onset ASPD subtype may develop in clients with severe mental illness secondary to substance abuse, but that much criminal behavior in clients with dual disorders may be due to the early onset of the full ASPD syndrome in this population and not the effects of substance use disorders.

Public Domain

Nesvag R; Frigessi A; Jonsson EG; Agartz I. Effects of alcohol consumption and antipsychotic medication on brain morphology in schizophrenia. Schizophrenia Research 90(1-3): 52-61, 2007. (51 refs.)

Magnetic resonance imaging (MRI) studies have shown smaller volumes of grey matter (GM) and white matter (WM) both in schizophrenia and among patients with alcohol abuse or dependence. The effect of alcohol consumption in non-clinical alcohol consumers, i.e. subjects not recruited as having alcohol use disorders is less studied. In the present study, we investigated the effects of alcohol consumption, antipsychotic medication and a diagnosis of schizophrenia on variation in brain volumes among patients recruited for having schizophrenia and a group of age and gender matched control subjects. A total of 69 patients with schizophrenia (n=56), schizoaffective disorder (n=12) and schizophreniform disorder (n=1) and 97 control subjects were included. Alcohol Use Disorder Identification Test (AUDIT) was used to estimate alcohol consumption. In the entire group of patients and controls higher AUDIT score was significantly related to smaller volumes of WM. When ten patients and six control subjects who met lifetime diagnostic criteria for alcohol use disorders were excluded only a trend level association between AUDIT score and WM volumes was found. Having a diagnosis of schizophrenia was related to smaller volumes of total, frontal and temporal WM, total and temporal GM, and larger volumes of total, frontal and temporal cerebrospinal fluid (CSF). A diagnosis of schizophrenia remained a significant factor for smaller WM volumes even when the effect of alcohol consumption was taken into account. Antipsychotic medication was related to larger volumes of temporal CSF. This study demonstrates that alcohol consumption is an important factor for variation in WM volumes, and this effect should be taken into account in all studies evaluating brain volumes from MR images.

Nidecker M; DiClemente CC; Bennett ME; Bellack AS. Application of the Transtheoretical Model of change: Psychometric properties of leading measures in patients with co-occurring drug abuse and severe mental illness. Addictive Behaviors 33(8): 1021-1030, 2008. (53 refs.)

People with severe mental illness (SMI) have high rates of substance use disorders. The Transtheoretical Model (TTM) is a framework for understanding behavior change. There are five leading measures associated with the TTM - University of Rhode Island Change Assessment, Processes of Change Scale, Decisional Balance Scale, Abstinence Self-Efficacy Scale, and Temptation to Use Drugs Scale. While these measures have been found to be reliable and valid in primary substance abusers, it is unknown if these measures are relevant in people with co-occurring SMI and substance use disorders (SUD). We evaluated the psychometric properties of these measures in a sample (n = 240) of people with co-occurring disorders. Participants met DSM-IV criteria for schizophrenia/schizoaffective disorder or non-psychotic affective disorder, and current cocaine dependence or cocaine dependence in remission. All subscales showed good reliability and validity in the total sample. Analyses within diagnostic groups showed good reliability and validity in most groups, with some falling off in the affective disorders and remitted cocaine dependence groups. Overall, findings support the use of these measures in people with co-occurring disorders.

Padgett DK; Hawkins RL; Abrams C; Davis A. In their own words: Trauma and substance abuse in the lives of formerly homeless women with serious mental illness. American Journal of Orthopsychiatry 76(4): 461-467, 2006. (34 refs.)

In-depth interviews were conducted with 13 formerly homeless mentally ill women to capture their individual life trajectories of mental illness, substance abuse, and trauma in their own words. Cross-case analyses produced 5 themes: (a) betrayals of trust, (b) graphic or gratuitous nature of traumatic events, (c) anxiety about leaving their immediate surroundings (including attending group treatment programs), (d) desire for one's own space, and (e) gender-related status loss and stigmatization. Findings suggest formerly homeless mentally ill women need (and want) autonomy, protection from further victimization, and assistance in restoring status and devalued identity. Avenues for intervention include enhanced provider training, addressing experiences of betrayal and trauma, and more focused attention to current symptoms rather than previous diagnoses.

Polesskaya OO; Smith RF; Fryxell KJ. Chronic nicotine doses down-regulate PDE4 isoforms that are targets of antidepressants in adolescent female rats. Biological Psychiatry 61(1): 56-64, 2007. (100 refs.)

Background: Previous data in humans and animal models has suggested connections between anxiety, depression, smoking behavior, and nicotine dependence. The importance of these connections has been confirmed by clinical studies that led to the recent FDA approval of an anti-depressant (Zyban) for use in human smoking cessation programs. Other anti-depressants (such as rolipram) specifically inhibit PDE4 phosphodiesterases. Methods: We used DNA microarrays to discover gene expression changes in adolescent female rats following chronic nicotine treatments, and real-time PCR assays to confirm and extend those results.ResultsWe found a consistent decrease in the mRNA levels encoded by the Pde4b gene in nucleus accumbens, prefrontal cortex, and hippocampus of adolescent female rats treated with .24 mg/day nicotine, and in prefrontal cortex of adolescent female rats treated with .12 mg/day nicotine. We further show that each of these brain areas produced a different profile of Pde4b isoforms. Conclusions: Chronic nicotine treatments produce a dose-dependent down-regulation of Pde4b, which may have an antidepressant effect. This is the first report of a link between nicotine dependence and phosphodiesterase gene expression. Our results also add to the complex interrelationships between smoking and schizophrenia, because mutations in the PDE4B gene are associated with schizophrenia.

Pollack HA; Reuter P. The implications of recent findings on the link between cannabis and psychosis. Addiction 102(2): 173-176, 2007. (23 refs.)

This is a commentary on a report in this issue, "Cannabis and schizophrenia: model projections of the impact of the rise in cannabis use on historical and future trends in schizophrenia in England and Wales." This commentary raises questions about both the clinical and policy implications. Assuming the posited relationship exists, then the social costs of marijuana use are substantially greater.

Potvin S; Joyal CC; Pelletier J; Stip E. Contradictory cognitive capacities among substance-abusing patients with schizophrenia: A meta-analysis. Schizophrenia Research 100(1-3): 242-251, 2008. (64 refs.)

Although a substance use disorder (SUD) is traditionally associated with psycho-bio-social impairments, recent investigations among persons with schizophrenia (Sz) generated divergent results. Certain persons with Sz+SUD might in fact present better social and cognitive functioning than persons with Sz without SUD. This meta-analysis was conducted to verify this counterintuitive possibility and to determine whether factors such as substance type, severity or nature of psychotic symptoms and age of the patients help discriminate these subgroups. Twenty-three studies met the inclusion criteria and data from 1807 persons with schizophrenia, with or without comorbid SUD, were available for analyses. As a group, persons with Sz+ SUD did not obtain significantly higher scores at a Global Cognitive Index than persons with Sz without SUD, although they were better at the Trail Making Task and the speed processing domain. Secondary analyses showed the importance of considering intermediate factors, particularly the preferred substance used and the mean age. While consumption of alcohol was associated with a global cognitive scores similar to that of persons with Sz without an SUD and lower working memory capacities, preferential use of cannabis was instead associated with higher scores for problem solving and reasoning and visual memory. Age was inversely related to the size of the effects. It is concluded that previous mixed results obtained with cognitive evaluations of persons with Sz+SUD might reflect the heterogeneity of participants and that subgroups of patients might be defined on the basis of intermediate factors.

Potvin S; Stip E; Lipp O; Roy MA; Demers MF; Bouchard RH et al. Anhedonia and social adaptation predict substance abuse evolution in dual diagnosis schizophrenia. American Journal of Drug and Alcohol Abuse 34(1): 75-82, 2008. (25 refs.)

The current study sought to identify the variables, derived from the self-medication hypothesis, which predicted substance abuse evolution during a homogeneous 3-month antipsychotic treatment. Twenty-four patients were diagnosed with schizophrenia and substance abuse (mainly cannabis and alcohol). Substance abuse, psychiatric symptoms, anhedonia, and social adjustment were assessed at baseline and study endpoint. Linear regression analyses were performed. Better social adaptation and worse anhedonia predicted substance abuse improvements. Conversely, greater psychoactive substance (PAS) use predicted endpoint positive and depressive symptoms. These results suggest that: (i) substance abuse interferes with psychiatric prognosis in schizophrenia; and (ii) dual diagnosis treatments leading patients to engage in alternative social activities may render substance abuse less appealing. Further studies are warranted to dissociate the causes and consequences of substance abuse in schizophrenia.

Potvin S; Stip E; Lipp O; Elie R; Mancini-Marie A; Demers MF et al. Quetiapine in patients with comorbid schizophrenia-spectrum and substance use disorders: An open-label trial. Current Medical Research and Opinion 22(7): 1277-1285, 2006. (40 refs.)

Background: Preliminary evidence suggests that clozapine relieves the craving for psychoactive substances in schizophrenia patients. Quetiapine shares crucial pharmacological properties with clozapine. Promising results have been described with quetiapine therapy in patients with psychosis and substance use disorder. Methods: Based on Diagnostic and Statistical Manual of Mental Disorders-fourth edition (DSM-IV) criteria, patients were diagnosed with comorbid schizophrenia-spectrum and substance use disorders. Patients were switched to quetiapine for a 12-week open-label trial. Craving, quantities used, days of consumption, and severity of substance abuse were assessed every 3 weeks. Alcohol and Drug Use Scales were administered on baseline and end-point. Psychiatric symptoms, depressive symptoms, extrapyramidal symptoms, and cognition were also assessed at baseline, week 6 and week 12. Results: Twenty-four schizophrenia-spectrum patients were included in the last observation carried forward (LOCF) analyses, responding to one or more of the following substance use disorders: cannabis ( 15 patients), alcohol ( 10 patients), and other psychoactive substances ( nine patients). Overall, severity of substance abuse improved during the study. Less weekly days were spent on drugs of abuse. A decrease in the weekly Canadian dollars spent on psychoactive substances was also observed. Cognition, psychiatric, depressive, and extrapyramidal symptoms also significantly improved ( p < 0.05). Conclusions: In this open-label, uncontrolled trial, significant improvements were noted in substance abuse, psychiatric symptoms, extrapyramidal symptoms, and cognition during quetiapine therapy. The study suffered from three main limitations: ( 1) the open-label design of the study; ( 2) the patients' poor compliance; and ( 3) the small sample size involved. Controlled studies on the use of quetiapine in dual diagnosis schizophrenia are warranted to confirm that the effects are drug-related.

Pray ME; Watson LM. Effectiveness of day treatment for dual diagnosis patients with severe chronic mental illness. Journal of Addictions Nursing 19(3): 141-149, 2008. (40 refs.)

This study examined the clinical outcomes of dual diagnosis patients with severe chronic mental illness and a secondary diagnosis of an addictive substance (N = 48) who attended a daily Day Treatment Center (DTC). Clinical interventions included the DTC program plus weekly dual diagnosis groups. Outcome measures included urine toxicology screens, Global Assessment of Functioning (GAF) scores, relapses, and hospitalizations. Results revealed that the length of stay (LOS) in the DTC program was the only statistically significant predictor of both pre and post study GAF scores for all three groups. Patients with one year of remission were less likely to relapse. The longer the patient's stay in the DTC program, the better the treatment outcome.

Ringen PA; Lagerberg TV; Birkenaes AB; Engh JA; Faerden A; Jonsdottir H et al. Differences in prevalence and patterns of substance use in schizophrenia and bipolar disorder. Psychological Medicine 38(9): 1241-1249, 2006. (46 refs.)

Background. Schizophrenia and bipolar disorder have partly overlapping clinical profiles, which include In over-representation of substance-use behaviour. There are few previous studies directly comparing substance-use patterns in the two disorders. The objective of the present study was to compare the prevalence of substance use in schizophrenia and bipolar disorder, and investigate possible differences in pattern and frequency of use. Method. A total of 336 patients with schizophrenia or bipolar spectrum disorder from a catchment area-based hospital service were included in a cross-sectional study. In addition to thorough clinical assessments, patients were interviewed about drug-use history, habits and patterns of use. The prevalence and drug-use patterns were compared between groups. Results. Patients with bipolar disorder bad higher rates of alcohol consumption, while schizophrenia patients more often used centrally Stimulating substances, had more frequent use of non-alcoholic drugs and more often used more than one non-alcoholic drug. Single use of cannabis was more frequent in bipolar disorder. Conclusions. The present study showed diagnosis-specific patterns of substance use in severe mental disorder. This suggests a need for more disease-specific treatment strategies, and indicates that substance use may be in important factor in studies of overlapping disease mechanisms.

Ringen PA; Melle I; Birkenaes AB; Engh JA; Faerden A; Vaskinn A et al. The level of illicit drug use is related to symptoms and premorbid functioning in severe mental illness. Acta Psychiatrica Scandinavica 118(4): 297-304, 2008. (37 refs.)

Objective: There is conflicting data on drug abuse and outcome in severe mental illness. This study aims to investigate if the amount of illicit psychoactive drug use is related to symptom load or premorbid functioning across diagnosis in patients with severe mental illness. Method: Symptom load, sociodemographic status, premorbid functioning and the level of use of illicit psychoactive drugs were assessed in 423 subjects with schizophrenia or bipolar disorder in a cross-sectional study. Results: High amount of illicit drug use was associated with poorer premorbid academic functioning. In schizophrenia, there was a significant positive association between amount of drug use and severity of psychiatric symptoms. The association between symptom load and drug use was significant after controlling for premorbid functioning. Conclusion: The results suggest a direct association between the quantity of current drug use and more severe symptoms in schizophrenia. Poor premorbid functioning was related to high amount of use, but did not explain the difference in symptom load.

Roncero C; Collazos F; Valero S; Casas M. Cannabis consumption and development of psychosis: State of the art. (review). Actas Esponolas de Psiquiatria 35(3): 182-189, 2007. (30 refs.)

Cannabis is the most widely used illegal drug in Spain. Currently, its use is on the rise as risk perception is decreasing, primarily among young people. It is well known that cannabis negatively influences course and prognosis in schizophrenic patients. However, the relationship between cannabis use and development of a psychotic or schizophrenic disorder remains controversial. The study of this topic has been approached using longitudinal cohort studies, which study cannabis use and psychotic or schizophrenic disorders. In addition to the classic Swedish conscript study published by Andreasson et al. 1987, during the past years, six more longitudinal cohort studies have been published. The data demonstrate that there are both temporal and dose-response relationships, and that early initiation of cannabis use is highly correlated with the development of psychotic symptoms. Cannabis consumption can increase the risk of developing schizophrenia in a vulnerable population twofold, to the extent that some studies suggest a causal relationship. The current knowledge base makes it necessary to warn the population about the relationship between cannabis use and the development of psychosis.

Rounsaville BJ. DSM-V research agenda: Substance abuse/psychosis comorbidity. Schizophrenia Bulletin 33(4): 947-952, 2007. (29 refs.)

For diagnosis of patients with comorbid psychotic symptoms and substance use disorders (SUDs), Diagnostic and Statistical Manual of Mental Disorders, Fourth Edition, makes clear distinctions between independent psychotic disorders (eg, bipolar disorder, schizophrenia) and substance-induced syndromes (eg, delirium, dementias). Most substance-induced psychotic symptoms are considered to be short lived and to resolve with sustained abstinence along with other symptoms of substance intoxication and withdrawal. These guidelines are challenged by practical difficulties in distinguishing between substance-induced and independent psychoses and by mounting evidence that marijuana use may be a contributing cause of schizophrenia. To inform the diagnostic distinction between substance-induced vs independent psychotic symptoms, 2 kinds of information could be sought from longitudinal research: (a) identification of early markers that clearly differentiate the 2 conditions and (b) more precise information about duration of psychotic symptoms induced by different substances. Evidence of this type could emerge from reanalysis of existing data from large-scale longitudinal studies of community samples. To inform possible nosological changes related to the possible schizophrenia-inducing role of marijuana (eg, designating a "cannabis-induced" subtype), a wide range of research evidence will be needed to clarify the relationship between effects of cannabis and schizophrenia symptoms. Ultimately, the ideal psychiatric nomenclature will define syndromes on the basis of established etiology and/or pathophysiology. Given the strong association between SUDs and psychotic disorders, research on the neurobiology of psychotic disorders could fruitfully include subjects with comorbid SUDs to shed light on shared etiology and pathophysiology.

Sacks S; Banks S; McKendrick K; Sacks JY. Modified therapeutic community for co-occurring disorders: A summary of four studies. Journal of Substance Abuse Treatment 34(1): 112-122, 2008. (35 refs.)

This article summarizes results from four research studies (n = 902) that examined the effectiveness of the modified therapeutic community (MTC) for clients with co-occurring disorders (most with severe mental disorders). Significantly better outcomes for MTC were found across four experimental versus control comparisons on 23.1% (12 of 52) of primary outcome measures of substance use, mental health, crime, HIV risk, employment, and housing. Study limitations included the potential for selection bias, limited measurement of program fidelity, and insufficient examination of the relationship between treatment dose and outcome. Future research should emphasize clinical trial replications, multiple outcome domains, and further development of continuing care models. Given the need for research-based approaches, the MTC warrants consideration when program and policy planners are designing programs for co-occurring disorders.

San L; Arranz B; Martinez-Raga J. Antipsychotic drug treatment of schizophrenic patients with substance abuse disorders. (review). European Addiction Research 13(4): 230-243, 2007. (102 refs.)

Background/Aim: In recent years, there has been a growing interest in developing adequate treatments for patients with a diagnosis of schizophrenia and a comorbid substance use disorder (SUD). In the present paper we aim to critically review published reports on the use of conventional and second-generation antipsychotics in the treatment of patients with schizophrenia and comorbid SUD, to provide clinicians with a clearer view of the pharmacological treatment of this highly prevalent dual diagnosis based upon the evidence arising from the scientific literature. Methods: A search of the relevant literature from Medline, PsycLIT and EMBASE databases, included in the Science Citation Index, and available up to November 2006 was conducted using the terms: `schizophrenia', `substance use disorder' and `antipsychotics'. Results: While research on the use of conventional antipsychotics has remained limited, the majority of studies suggest the effectiveness of second-generation antipsychotics, particularly clozapine, for patients with schizophrenia and a comorbid substance use disorder. Conclusion: In the absence of randomized controlled trials that could provide more reliable information, clinical decisions may need to rely on indirect data provided by the increasing number of case reports, open trials and retrospective studies showing a decrease in cigarette smoking, alcohol, cocaine or cannabis use and an improvement of overall psychiatric symptoms.

Shoval G; Zalsman G; Apter A; Diller R; Sher L; Weizman A. A 10-year retrospective study of inpatient adolescents with schizophrenia/schizoaffective disorder and substance use. Comprehensive Psychiatry 48(1): 1-7, 2007. (62 refs.)

The comorbidity of schizophrenia/schizoaffective disorder and substance use is a major psychiatric concern that is associated with aggressive and suicidal behavior. This study investigated the clinical correlates and characterizes adolescent psychotic inpatients with and without comorbid substance use. We performed a retrospective study of 188 adolescent inpatients who were admitted between the years 1994 and 2004 to the inpatient unit of Geha Mental Health Center and who were diagnosed as suffering from either. schizophrenia or schizoaffective disorder. The substance-using psychotic inpatients were found to have more relatives with substance-related disorders, fewer comorbid anxiety disorders, lower scores on the Brief Psychiatric Rating Scale and Hamilton Scale for Depression, higher scores on the Overt Aggression Scale, and they were more suicidal than the nonsubstance using inpatients. Adolescent inpatients with schizophrenia and schizoaffective who use substances possess differential clinical characteristics and particular correlates that justify adopting a specific approach to this high-risk clinical subgroup.

Sigmon SC; Higgins ST. Voucher-based contingent reinforcement of marijuana abstinence among individuals with serious mental illness. Journal of Substance Abuse Treatment 30(4): 291-295, 2006. (13 refs.)

Previous studies by our group have used money given contingent on abstinence to reduce drug use by individuals with schizophrenia. In this study, we examined the sensitivity of marijuana use by individuals with serious mental illness to voucher-based contingent reinforcement. which represents the first study to date investigating the efficacy of voucher incentives with this population. This within subject reversal design consisted of three conditions: 4-week baseline, 12-week voucher intervention, and 4-week baseline. During baseline periods. subjects received US$10 vouchers per urine specimen, independent Of urinalysis results. During voucher intervention, only specimens testing negative for marijuana earned vouchers, with total possible earnings of US$930. Seven adults with schizophrenia or other serious mental illnesses participated in the study. The percentage of marijuana-negative specimens was significantly greater during voucher intervention than during baseline periods. These results provide evidence that marijuana use among individuals with serious mental illness is sensitive to voucher-based incentives and further support the potential feasibility of using voucher-based contingency management to reduce substance abuse in this challenging population.

Smith J. Co-occurring Substance Abuse and Mental Disorders: A Practitioner's Guide. New York: Jason Aronson, 2007

This volume provides a basic overview of current evidence-based practices for treating co-occurring disorders. It is organized into eight chapters. Following an introductory chapter explaining what constitutes co-occurring disorders, individual chapters address assessment, major mental disorders, addictive disorders, psychotropic medications, and an overview of treatment approaches. The concluding chapter provides clinical case studies, illustrating the material.

Stasiewicz PR; Vincent PC; Bradizza CM; Connors GJ; Maisto SA; Mercer ND. Factors affecting agreement between severely mentally ill alcohol abusers' and collaterals' reports of alcohol and other substance use. Psychology of Addictive Behaviors 22(1): 78-87, 2008. (45 refs.)

This study examined subject-collateral reports of alcohol use among a sample of 167 dually diagnosed individuals seeking outpatient treatment at a community mental health clinic. All subjects met Diagnostic and Statistical Manual of Mental Disorders (4th ed.; American Psychiatric Association, 1994) criteria for a schizophrenia-spectrum or bipolar disorder and for alcohol abuse or dependence. Subjects were recruited within 2 weeks of treatment entry and completed measures of cognitive functioning, alcohol dependence severity, psychiatric symptoms, and quantity and frequency of substance use over the previous 60 days using the Timeline Follow-Back interview (L. C. Sobell & M. B. Sobell, 1996). They also provided a urine sample, which was screened for recent drug use. Collateral interviews were conducted by phone and included an assessment of the subject's alcohol and drug use over the same 60-day period. Collaterals also reported their confidence in the accuracy of their reports. Overall, the results indicated generally poor subject-collateral agreement. However, subject-collateral agreement appeared better for those individuals (n = 97) with negative urine drug screens. The most consistent predictor of subject-collateral discrepancy scores was subjects' recent drug use. Recommendations for enhancing the validity of self-reports of substance use in a severely mentally ill population are discussed.

Stuyt EB; Sajbel TA; Allen MH. Differing effects of antipsychotic medications on substance abuse treatment patients with co-occurring psychotic and substance abuse disorders. American Journal on Addictions 15(2): 166-173, 2006. (33 refs.)

This retrospective study of patients treated in a ninety-day, inpatient, dual-diagnosis treatment program examined antipsychotic effectiveness in this population using length of stay in treatment and successful program completion as outcome measures. All patients with co-occurring substance dependence and schizophrenia or schizoaffective disorder treated with olanzapine, risperidone, ziprasidone, and typical depot neuroleptics from January 2001 to December 2003 (N = 55) are the subjects of this study. Patients stayed longer in treatment when taking risperidone ( 82 +/- 19 days) or ziprasidone ( 74 +/- 21 days) compared with olanzapine ( 44 +/- 30 days) or typicals ( 47 +/- 36 days). Eighty-eight percent of risperidone patients and 64% of ziprasidone patients successfully completed the program, while only 33% of olanzapine patients and 40% of patients on typicals successfully completed the program. Risperidone and ziprasidone were associated with significantly better program performance than olanzapine or depot typicals in this population. Possible reasons for this difference are discussed.

Swartz JA; Lurigio AJ. Screening for serious mental illness in populations with co-occurring substance use disorders: Performance of the K6 scale. Journal of Substance Abuse Treatment 31(3): 287-296, 2006. (44 refs.)

Serious mental illnesses (SMIs) such as schizophrenia, bipolar disorder, and major depression are prevalent among individuals with substance use disorders, particularly those in drug treatment programs. No screening tool has yet become the gold standard for identifying SMI among individuals with substance use disorders. One candidate instrument, the K6 screening scale, is brief, easy to administer and score, and has performed well, detecting SMI in studies using general population samples. We used data from the National Survey on Drug Use and Health to examine the K6's psychometric properties in a subsample of persons with substance use disorders and found that the K6 accurately screened for severe psychological distress associated with SMI among individuals with substance use disorders and across different psychiatric disorders.

Swartz MS; Wagner HR; Swanson JW; Stroup TS; McEvoy JP; Canive JM et al. Substance use in persons with schizophrenia: Baseline prevalence and correlates from the NIMH CATIE study. Journal of Nervous and Mental Disease 194(3): 164-172, 2006. (38 refs.)

This study examined baseline correlates of substance use in the NIMH Clinical Antipsychotic Trials of Intervention Effectiveness project. Approximately 60% of the sample was found to use substances, including 37% with current evidence of substance use disorders. Users (with and without substance use disorders), compared with nonusers, were significantly more likely to be male, be African-American, have lower educational attainment, have a recent period of homelessness, report more childhood conduct problems, have a history of major depression, have lower negative symptom and higher positive symptom scores on the Positive and Negative Syndrome Scale, and have a recent illness exacerbation. Individuals with comorbid substance use disorders were significantly more likely to be male, report more childhood conduct problems, have higher positive symptom scores on the Positive and Negative Syndrome Scale, and have a recent illness exacerbation. These analyses suggest that substance use disorders in schizophrenia are especially common among men with a history of childhood conduct disorder problems and that childhood conduct disorder problems are potent risk factors for substance use disorders in schizophrenia.

Tiet QQ; Mausbach B. Treatments for patients with dual diagnosis: A review. (review). Alcoholism: Clinical and Experimental Research 31(4): 513-536, 2007. (96 refs.)

Background: Comorbid substance use and mental illness is prevalent and often results in serious consequences. However, little is known about the efficacy of treatments for patients with dual diagnosis. Methods: This paper reviews both the psychosocial and medication treatments for those diagnosed with a substance-related disorder and one of the following disorders: (a) depression, (b) anxiety disorder, (c) schizophrenia, (d) bipolar disorder, (e) severe mental illness, and (f) nonspecific mental illness. We made no restriction of study design to include all published studies, due to the dearth of studies on treatments of patients with dual diagnosis. Results: Fifty-nine studies were identified (36 randomized-controlled trials; RCT). Limited number of studies, especially RCTs, have been conducted within each comorbid category. This review did not find treatments that had been replicated and consistently showed clear advantages over comparison condition for both substance-related and other psychiatric outcomes. Conclusions: Although no treatment was identified as efficacious for both psychiatric disorders and substance-related disorder, this review finds: (1) existing efficacious treatments for reducing psychiatric symptoms also tend to work in dual-diagnosis patients, (2) existing efficacious treatments for reducing substance use also decrease substance use in dually diagnosed patients, and (3) the efficacy of integrated treatment is still unclear. This review provides a critique of the current state of the literature, identifies the directions for future research on treatment of dual-diagnosis individuals, and calls for urgent attention by researchers and funding agencies to conduct more and more methodologically rigorous research in this area.

Tsuang J; Fong TW; Lesser I. Psychosocial treatment of patients with schizophrenia and substance abuse disorders. Addictive Disorders and Their Treatment 5(2): 53-66, 2006. (98 refs.)

Substance abuse among patients with schizophrenia is quite common, with at least half of these individuals having a lifetime diagnosis of a substance abuse disorder. These so called "dual diagnosis" or "co-occurring disorder" patients have an increased utilization of medical and psychiatric services. They are more difficult to treat and usually have a worse prognosis as compared with non-substance abusing patients with schizophrenia. Fortunately, in recent years, the treatment of dually diagnosed patients has significantly improved. It has been established that the best treatment of these patients includes enrollment in an integrated program that treats both mental illness and substance abuse problems simultaneously. Previously, we published an article that reviewed the available psychopharmacological options for treatment of co-occurring disorder patients. This article will focus more on the psychosocial treatment modalities that have been used to reduce the psychiatric morbidity and substance relapse in these patients.

Urbanoski KA; Cairney J; Adlaf E; Rush B. Substance abuse and quality of life among severely mentally ill consumers - A longitudinal modelling analysis. Social Psychiatry and Psychiatric Epidemiology 42(10): 810-818, 2007. (37 refs.)

Background: Evidence suggests that substance abuse negatively affects both psychiatric symptom severity and quality of life (QOL) in people with severe mental illness (SMI). However, these relationships have not been examined simultaneously, nor have they been characterized over time. Thus, it is difficult to appreciate the extent to which substance abuse exerts an enduring effect on psychiatric symptoms and distress and/or QOL in this population. The purpose of this study is to test a conceptual model linking these factors together. Methods: Subjects were participants in a longitudinal evaluation of community mental healthcare in Ontario (n = 133). Comprehensive consumer assessments were conducted at treatment entry, and at 9 and 18 months. Subjects were receiving intensive case management or assertive community treatment throughout the 18-month study period. Structural equation modelling was used to examine the concurrent and longitudinal relationships between substance abuse, symptoms and distress, and QOL. Results The prevalence of substance abuse was 55.0%. The SEM analysis suggested that substance abuse at baseline was associated with elevated symptomatology and distress and lower QOL, and that these effects endured after 18 months of treatment. Psychiatric symptoms and distress mediated the negative relationship between substance abuse and QOL. Conclusions: The mediating role played by symptom and distress levels in the relationship between substance abuse and QOL suggests the importance of closely monitoring changes in these factors among SMI patients with substance problems. Tracking symptom severity and distress levels over time will allow service providers to intervene and potentially improve the QOL of individuals with SMI.

Varnas K; Okugawa G; Hammarberg A; Nesvag R; Rimol LM; Franck J et al. Cerebellar volumes in men with schizophrenia and alcohol dependence. Psychiatry and Clinical Neurosciences 61(3): 326-329, 2007. (15 refs.)

The aim of the present study was to investigate the variation in cerebellar morphology in schizophrenia and alcohol dependence. Volumetric measurements of cerebellar structures were performed using magnetic resonance imaging in 17 men with schizophrenia, nine men with alcohol dependence, and 18 healthy men. Schizophrenia patients had smaller volumes of the posterior superior vermis, while alcohol-dependent patients had smaller volumes of both the anterior and the posterior superior vermis compared with controls. The groups were not significantly different with respect to cerebellar hemisphere volumes. The results provide indications for differential morphological abnormalities of the cerebellar vermis in patients with schizophrenia and alcohol dependence.

Vornik LA; Brown ES. Management of comorbid bipolar disorder and substance abuse. Journal of Clinical Psychiatry 67(Supplement 7): 24-30, 2006. (64 refs.)

Bipolar disorder is a severe and often chronic disorder with lifetime prevalence rates of bipolar spectrum disorders of up to 6.5% in the general population. Patients with bipolar disorder frequently report co-occurring substance use disorders, and the rates of alcohol and other substance use disorders are significantly higher in persons with bipolar disorder than in the general population. The present review discusses why people with bipolar disorder use substances, provides an overview of the impact of alcohol and other substance use on the course of bipolar disorder, and outlines the treatment options currently available to patients with co-occurring bipolar disorder and substance abuse. Our aim is to summarize the existing data on the pharmacologic treatment options and to include the most recent published data whenever possible. Three randomized, placebo-controlled studies of dual-diagnosis patients treated with carbamazepine, lithium, and valproate are discussed. The results are generally positive and support the use of these agents in dual-diagnosis patients. Open-label studies are also presented, and the need for controlled data is outlined. The review also briefly discusses the psychotherapeutic approaches to patients with comorbid bipolar and substance use disorders.

Westermeyer J. Comorbid schizophrenia and substance abuse: A review of epidemiology and course. (review). American Journal on Addictions 15(5): 345-355, 2006. (99 refs.)

Over the last dozen years, our knowledge regarding comorbid schizophrenia (SCZ) and substance use disorder (SUD) has evolved in several ways. First, the rate of lifetime comorbid SCZ-SUD appears to have increased another 20-30%, so now about 70-80% of persons with SCZ have lifetime SUD. Second, early remission of SUD has become commonplace among patients with SCZ, perhaps outnumbering the number of SCZ-only patients as well as those with active SCZ-SUD. Third, sustained SUD remission is well demonstrated, though the rates may yet be low. Fourth, research on comorbid SCZ-SUD is filling out our knowledge in many areas, including the characteristics of SCZ patients at risk for SUD, reasons SCZ patients seek out substances, effects of various substances on SCZ course and symptoms, and obstacles to SUD recovery in people with SCZ. The influence of SUD treatment and self-help on epidemiology and course has not been adequately evaluated. Primary prevention and early treatment of SUD in SCZ patients are still relatively neglected, though they offer our greatest hope for enhancing the lives of people with SCZ and improving the cost efficacy of care.

Zhang AY; Harmon JA; Werkner J; McCormick RA. The long-term relationships between the motivation for change and alcohol use severity among patients with severe and persistent mental illness. Journal of Addictive Diseases 25(1): 121-128, 2006. (37 refs.)

This study examined the long-term relationship of changes in the motivation to remedy alcohol abuse to alcohol use severity among patients with a dual diagnosis of substance abuse disorder and severe and persistent mental illness. Linear regression analyses showed that patients who increasingly recognized alcohol use problems over a 9-month period exhibited significantly greater alcohol use severity at 9 months and a significant increase in alcohol use severity over time. Moreover, patients who became increasingly determined to take actions against alcohol use over a 9-month period exhibited significantly lower alcohol use severity at 9 months and a significant decrease in alcohol use severity over time. The findings support Prochaska////'s transtheoretical model of the motivation for change. They suggest that the recognition of alcohol use problems comes along with learning adverse consequences of alcohol use and that increased determination to take actions is critical to the long-term behavioral changes in alcohol use.